There are  13 surveys for this facility. Please select a date to view the survey results.

The agency failed to establish and maintain a comprehensive emergency preparedness program, including failure to conduct an all-hazards risk assessment, define the patient population served, maintain staff training documentation, and conduct and document required emergency preparedness exercises.
All active patients were reviewed to identify those at higher risk during emergencies. An emergency contact verification was completed for all active patients. Patients and/or caregivers were provided education on emergency preparedness. Updated emergency contact sheets and individualized emergency plans were placed in each patient's clinical record.
To identify additional patients who may have been affected by the deficient practice, the agency conducted a review of all active patient records. Any missing or incomplete information was corrected, and patients were contacted to update emergency planning documentation.
To prevent recurrence the agency completed a full revision of its Emergency Preparedness Program to ensure compliance with the regulations. All new employees receive emergency preparedness training at orientation. All staff, contractors, and volunteers receive refresher training at least every two (2) years. The agency has implemented a testing schedule that includes per regulations.
To ensure sustained compliance and prevent recurrence, the agency has incorporated emergency preparedness oversight into its Quality Assurance and Performance Improvement (QAPI) program. The Administrator will conduct semi-annual reviews of the emergency preparedness plan, verify completion of required training and exercises and review patient emergency preparedness documentation during quarterly clinical record audits. Emergency preparedness compliance will be reviewed during quarterly QAPI meetings any identified deficiencies will result in immediate corrective action and staff retraining.
To identify additional patients who may have been affected by the deficient practice, the agency conducted a review of all active patient records. Any missing or incomplete information was corrected, and patients were contacted to update emergency planning documentation.
To prevent recurrence the agency completed a full revision of its Emergency Preparedness Program to ensure compliance with the regulations. All new employees receive emergency preparedness training at orientation. All staff, contractors, and volunteers receive refresher training at least every two (2) years. The agency has implemented a testing schedule that includes per regulations.

The agency conducted an immediate review and complete revision of the Emergency Preparedness Plan to ensure current practices, contact information, and procedures were accurate and reflective of present operations. The updated plan now reflects current patient care services, geographic service area, communication methods, and coordination with local emergency management agencies.
All active patients were provided updated emergency preparedness education and emergency contact information to ensure they are aware of current agency emergency procedures. Because the emergency preparedness plan applies to all patients served by the agency, the agency conducted a review of all active patient records to ensure compliance with the regulations. Any missing or outdated information was corrected and documented in the patient's clinical record. To prevent recurrence the Emergency Preparedness Plan will be reviewed and updated in accordance with the regulations.
The agency has implemented a compliance tracking log to maintain compliance with the requirements. This log is maintained by the Administrator and reviewed during quarterly management meetings.
The agency has incorporated emergency preparedness plan review into its Quality Assurance and Performance Improvement (QAPI) program. The Administrator will review the emergency preparedness plan annually to ensure ongoing relevance
The status of the emergency preparedness plan review will be reported during quarterly QAPI meetings to ensure compliance with the requirements. Any missed deadlines or deficiencies will result in immediate corrective action and administrative review.

The agency acknowledges the cited deficiency and has implemented corrective actions to ensure that its emergency preparedness plan is based on a documented facility-based and community-based all-hazards risk assessment, completed and updated at least every two (2) years in accordance with 42 CFR §484.102(a)(1)–(2). Systems have been implemented to ensure ongoing compliance and prevent recurrence. The agency conducted a comprehensive facility-based and community-based all-hazards risk assessment to identify threats that could affect operations and patient safety, based on the findings of the risk assessment, emergency response strategies were updated to address identified hazards. High-risk patients, including those dependent on electricity or requiring frequent skilled visits, were identified and flagged in their clinical records for priority response during emergencies.

The agency conducted a review of all active patient records to ensure compliance with the requirements, any missing information was obtained and documented.
To ensure compliance with the requirement the agency implemented a hazards risk assessment tool to identify hazards with specific response strategies.
The Administrator and or the Director of Nursing will be responsibility for completion of the risk assessment and review to ensure clinical risks are fully addressed.
The agency has incorporated risk assessment review into its ongoing Quality Assurance and Performance Improvement (QAPI) program. The Administrator will review the status of the all-hazards risk assessment annually and ensure a full assessment is completed no later than two years from the most recent assessment date. The risk assessment and any resulting changes to the emergency preparedness plan will be reviewed during quarterly QAPI meetings to ensure compliance with the requirements.
Any missed deadlines will be addressed through corrective action and administrative review.

The agency acknowledges the cited deficiency and has revised its Emergency Preparedness Plan to ensure that it clearly defines the patient population served, the services that can be provided during emergencies, and continuity of operations. Systems have been implemented to ensure that the plan remains current and is reviewed and updated in accordance with the requirements.
The agency revised its Emergency Preparedness Plan to include a detailed description of the patient population served. Each active patient's clinical record was reviewed to ensure that individualized emergency planning information was present and current. Patients and caregivers were re-educated on agency emergency procedures and how services would be modified or continued during an emergency.

The agency conducted a review of all active patient clinical records. Any missing or outdated information was corrected and documented in the clinical record.

To prevent recurrence patients population profile will be reviewed during each biennial emergency preparedness plan review.

To ensure ongoing compliance, the agency has incorporated emergency preparedness patient population review into its Quality Assurance and Performance Improvement (QAPI) program.

The Administrator and Director of Nursing will review patient population characteristics during quarterly clinical record audits and verify that emergency preparedness documentation remains aligned with the current patient census and service types. During quarterly QAPI meetings the emergency preparedness plan will be reviewed to confirm that it accurately reflects current patient needs, any identified changes in patient acuity, service types, or geographic coverage will trigger plan updates.

The agency acknowledges the cited deficiency and has implemented a comprehensive emergency preparedness training and testing program that is based on the emergency preparedness plan, all-hazards risk assessment, policies and procedures, and communication plan. Systems have been established to ensure the program is reviewed and updated at least every two (2) years in compliance with the regulations and that staff remain prepared to respond effectively during emergencies.

All active patients were reviewed to ensure emergency contact information, individualized emergency plans, and priority status were current. Staff were immediately re-educated on emergency procedures, including patient communication, evacuation considerations, and continuity of care during emergencies. Updated emergency preparedness information was communicated to patients and caregivers to ensure they understood how services would be provided or modified during an emergency.

The agency conducted a review of all active patient clinical records. Any missing documentation was corrected and entered into the clinical record.

To prevent recurrence the agency developed and implemented a comprehensive Emergency Preparedness Training and Testing Program aligned with the emergency preparedness plan, all-hazards risk assessment, policies and procedures, and communication plan.

The agency incorporated emergency preparedness training oversight into its Quality Assurance and Performance Improvement (QAPI) program to ensure the deficiency does not recur.

The Administrator will review training records quarterly to ensure all staff remain compliant with required training intervals. Verify that new hires receive emergency preparedness training during orientation. Quarterly QAPI meetings will be performed for compliance with the regulations.

The agency acknowledges the cited deficiency and has implemented a comprehensive emergency preparedness training program in compliance with the regulations. Systems are in place to ensure initial training, biennial refresher training, competency demonstration, and documentation are maintained. Monitoring through QAPI ensures sustainability and prevents recurrence.

All active staff, contractors, and volunteers were provided comprehensive emergency preparedness training consistent with their roles. All active patients' records were reviewed to ensure emergency contact information and individual care plans were current. Any gaps were corrected and documented. All patients and caregivers were informed of emergency procedures and what to expect in case of an emergency to ensure continuity of care.

The agency conducted a full review of all active patients to ensure emergency preparedness plans were current. For any patient whose record lacked updated emergency preparedness documentation, entries were corrected, and staff were instructed to maintain ongoing updates for future changes.

To prevent future deficiencies, the agency has implemented training to all new hires, contractors, and volunteers during orientation on emergency preparedness policies, procedures, and staff roles. All staff will receive emergency preparedness training per agency policy.

The agency has established ongoing monitoring through its QAPI program. The Administrator will review training logs quarterly to ensure all staff are current. A report summarizing training compliance and any corrective actions will be reviewed in QAPI meetings.

The agency acknowledges the cited deficiency and has implemented a comprehensive emergency preparedness testing program in compliance with the regulations. Systems are now in place to ensure annual and biennial exercises are conducted, analyzed, documented, and used to revise the emergency plan as needed. Ongoing monitoring through the QAPI program will ensure sustainability and prevent recurrence.

All staff participated in an initial tabletop exercise on April 08, 2026, using a clinically-relevant emergency scenario. Roles, communication, patient safety procedures, and continuity of care were reviewed. Patient emergency information, care plans, and communication procedures were verified to ensure readiness in the event of an actual emergency. All exercises, including the tabletop exercise, were documented in the agency's emergency preparedness log.

All patient records were reviewed to confirm current emergency preparedness information and ensure any gaps were corrected. Any patient records with outdated or incomplete emergency information were updated immediately.

To prevent future deficiencies, the agency has implemented an emergency preparedness testing. All staff will participate in an annual emergency preparedness exercise. Emergency preparedness testing exercise, staff participation, outcomes, and plan updates will be documented.

The agency has established ongoing monitoring through its QAPI program. The Administrator will review exercise documentation quarterly to ensure compliance with annual and biennial requirements. Any staff not participating in required exercises will be scheduled for make-up sessions. Reports of exercises, analyses, and revisions will be reviewed in the agency's annual QAPI meeting to ensure continued compliance and improvement.

Based on survey findings, the agency failed to ensure that a Registered Nurse (RN) conducted and documented the initial assessment, completed a comprehensive assessment including all required elements, reviewed medications, and updated the comprehensive assessment within the required timeframes. All patients identified in the survey sample were immediately reviewed by the Director of Nursing (DON).

The agency will conduct a 100% audit of all active and discharged patients for the previous 90 days to determine whether other patients were affected by the same deficient practice.
Any identified deficiencies will be corrected immediately by a Registered Nurse, and updated documentation will be placed in the patient's clinical record.
All clinical staff received mandatory re-education on the requirements, including timelines for SOC, ROC, and recertification, required components of the comprehensive assessment, and medication review standards. A standardized Start of Care and Recertification checklist was implemented to ensure all required elements of the comprehensive assessment are completed prior to submission.

On going thereafter: The agency incorporated monitoring of comprehensive assessment compliance into its Quality Assurance and Performance Improvement (QAPI) program. The Director of Nursing or designee will perform monthly audits of a minimum of 10% of active clinical records, including all new admissions for the first 60 days following implementation of this plan. Audit findings will be reviewed during quarterly QAPI meetings. Any identified trends or repeat deficiencies will result in additional staff training and corrective action.

The agency failed to ensure that a Registered Nurse conducted the initial assessment visit within 48 hours of referral, within 48 hours of the patient's return home, or on the physician ordered Start of Care date for six (6) of six (6) clinical records reviewed.

All six clinical records cited in the survey findings were immediately reviewed by the Administrator/Director of Nursing. For patients who remained active, a Registered Nurse conducted a face-to-face comprehensive assessment and completed all required admission documentation, including referral verification, initial assessment, plan of care, and certification period documentation. For patients who were discharged, the records were reviewed to determine whether care had been appropriately delivered.

The agency conducted a 100% audit of all admissions for the previous 12 months to identify additional patients who may have been affected by the same deficient practice.

Any record found to be incomplete or missing required documentation was corrected by the Director of Nursing or assigned Registered Nurse.
The agency revised its admission workflow to ensure compliance with the federal requirement that an RN completes the initial assessment within 48 hours of referral or physician-ordered start of care date. The following system changes were implemented: A referral tracking log was implemented.

On going, the agency has incorporated monitoring of initial assessment timeliness into its Quality Assurance and Performance Improvement (QAPI) program. Monitoring activities include: Weekly review of all new admissions by the Director of Nursing for 90 days to verify RN assessment completion within required timeframes. Monthly audits of 10% of all admissions thereafter to ensure continued compliance. Tracking of compliance rates on a QAPI dashboard reviewed during quarterly QAPI meetings. Immediate corrective action and retraining for any staff member found to be out of compliance.

The agency failed to ensure that the comprehensive assessment completed by a Registered Nurse included documentation of the patient's medical, nursing, rehabilitative, social, and discharge planning needs for six (6) of six (6) clinical records reviewed.

The agency conducted a 100% audit of all active and discharged patient records for the previous 90 days to determine whether other patients were affected by the same deficient practice. Any incomplete records identified during the audit were corrected by a Registered Nurse, and the comprehensive assessment and plan of care were updated accordingly. The agency implemented the following process changes: Admission and recertification workflows were updated to require supervisory review of the comprehensive assessment prior to finalization. All clinical staff received mandatory re-education on federal requirements and agency policy related to completion of the comprehensive assessment.

On going, compliance with comprehensive assessment requirements has been incorporated into the agency's Quality Assurance and Performance Improvement (QAPI) program. The Director of Nursing or designee will conduct audits of 100% of Start of Care assessments for 60 days, followed by monthly audits of at least 10% of active records. Audits will verify that all required patient needs are assessed and documented and that identified needs are reflected in the plan of care. Audit findings will be reviewed during quarterly QAPI meetings. Any identified trends or repeat deficiencies will result in immediate corrective action and additional staff training.

All six clinical records cited were immediately reviewed by the Administrator/Director of Nursing (DON). For each affected patient: A comprehensive assessment was reviewed or completed by a Registered Nurse. An individualized Home Health Certification and Plan of Care (POC) was developed based on the patient's current clinical status and identified needs. Plans of care were updated to include measurable goals, responsible disciplines, frequency of visits, medications, treatments, and patient/caregiver education. The revised plans of care were submitted to the attending physicians for review, signature, and certification. For active patients, services were aligned immediately with the updated physician-signed plan of care.

All six clinical records cited were immediately reviewed by the Administrator/Director of Nursing (DON). For each affected patient: A comprehensive assessment was reviewed or completed by a Registered Nurse. An individualized Home Health Certification and Plan of Care (POC) was developed based on the patient's current clinical status and identified needs. Plans of care were updated to include measurable goals, responsible disciplines, frequency of visits, medications, treatments, and patient/caregiver education. The revised plans of care were submitted to the attending physicians for review, signature, and certification. For active patients, services were aligned immediately with the updated physician-signed plan of care.

To ensure compliance comprehensive assessment will be reviewed within 5 days of the star of care date to ensure they include measurable goals and expected outcomes, responsible disciplines, medication and treatment orders, patient and caregiver education. A POC tracking log will be created to monitor: date of certification period start and end, Physician signature status, due dates for 60-day recertification and plan revisions. A physician signature tracking, and timely review of the plan of care was created to ensure POC are signed per policy. All clinical staff received mandatory re-education on federal care planning requirements and agency documentation standards.

On going, the agency has incorporated monitoring of initial assessment timeliness into its Quality Assurance and Performance Improvement (QAPI) program. Monitoring activities include: 100% review of all new admissions and recertifications for 90 days to ensure compliance with the requirements. After 90 days, the agency will conduct monthly audits of 10% of active clinical records. Audit results will be presented during quarterly QAPI meetings and trended to identify patterns or staff training needs. Any identified deficiencies will result in immediate corrective action, documentation correction, and staff retraining.

All six clinical records cited were immediately reviewed by the Administrator/Director of Nursing (DON). A Registered Nurse completed a comprehensive assessment or reviewed the most recent assessment to ensure it reflected the patient's current clinical status. A Home Health Certification and Plan of Care (Form 485) was developed for each patient, incorporating all required elements including diagnoses, functional limitations, mental and psychosocial status, medications, treatments, frequency and duration of visits, safety measures, and measurable goals. The plans of care were submitted to the attending physicians for review, signature, and certification. Services were aligned with physician orders once plans of care were signed, and documentation was updated to accurately reflect care provided.

The agency will conduct a 100% audit of all active and discharged patient records for the previous 12 months to identify any additional cases where a Home Health Certification and Plan of Care are missing, incomplete, or unsigned. Any additional records identified with missing or incomplete plans of care will be corrected immediately. New plans of care will be generated and submitted to physicians for signature and certification.
The agency implemented the following corrective system changes to ensure that all patients receive services under an individualized, physician-signed plan of care: A Plan of Care tracking log was implemented to monitor Inclusion of all required plan elements per agency policy and federal regulation. All clinical and administrative staff involved in admissions, scheduling, and documentation were provided mandatory re-education on federal plan of care requirements and agency policy.

The agency incorporated compliance monitoring into its Quality Assurance and Performance Improvement (QAPI) program. Monitoring activities include: 100% review of all new admissions and recertifications for 90 days to verify that a plan of care is developed, completed, and submitted to the physician within required timeframes. Monthly audits of at least 10% of clinical records thereafter to verify continued compliance with plan of care requirements. The Director of Nursing will track physician signature turnaround times and follow up with providers as needed. Audit findings and compliance trends will be reviewed during quarterly QAPI meetings, and corrective actions will be implemented if deficiencies are identified.

All six clinical records cited in the survey findings will be reviewed by the Administrator/Director of Nursing (DON) to ensure all current patient needs were identified. A complete and individualized Home Health Certification and Plan of Care will be developed and updated to include all required elements under federal regulation, including diagnoses, functional limitations, mental and psychosocial status, medications, treatments, safety measures, measurable goals, discharge planning, emergency preparedness planning, and patient/caregiver education. The plans of care were submitted to the attending physicians for review, approval, and signature. Services were reviewed and aligned with the updated physician-approved plan of care to ensure care was delivered in accordance with documented patient needs.

The agency will conduct a 100% audit of all active and recently discharged patient records for the previous 12 months to identify any additional patients whose plans of care did not contain all required elements. Any records found to be incomplete will be corrected by updating the plan of care and obtaining physician signature where required.

To prevent recurrence, A Plan of Care tracking log was implemented to monitor Inclusion of all required plan elements per agency policy and federal regulation. All clinical and administrative staff involved in admissions, scheduling, and documentation were provided mandatory re-education on federal plan of care requirements and agency policy.

On going, the agency has incorporated compliance with plan of care content requirements into its Quality Assurance and Performance Improvement (QAPI) program. Monitoring activities include: 100% review of all newly created plans of care for 90 days by the Director of Nursing or designee. Monthly audits of at least 10% of active clinical records thereafter to ensure that all required plan elements are consistently documented. Audit findings will be tracked and trended and reviewed during quarterly QAPI meetings to identify patterns and implement corrective actions when needed. Staff found to be noncompliant will receive immediate re-education and follow-up audits to ensure improvement.

All six clinical records cited will be immediately reviewed by the Administrator/Director of Nursing (DON). For each affected patient: The attending physicians will be contacted to obtain written orders authorizing all services, medications, and treatments that had been provided. A comprehensive review of each patient's medications, treatments, and services was conducted by a Registered Nurse to ensure they were appropriate and consistent with physician direction. Physician orders will be obtained and placed in the clinical record, and care plans will be updated to reflect these orders.

the agency will conduct a 100% audit of all active and discharged patient records for the previous 12 months to determine whether additional patients were affected by the same deficient practice. Any records identified as lacking physician authorization will be corrected by obtaining appropriate written orders and updating the clinical documentation.
To prevent recurrence: the agency will ensure that no patient is admitted or scheduled for services until physician orders are received and verified by the clinical supervisor. A Physician Order Verification log has been created to confirm that all services, medications, and treatments are authorized prior to the start of care. All nursing and administrative staff received mandatory re-education on this requirement and agency policy.

Compliance with physician order requirements has been incorporated into the agency's Quality Assurance and Performance Improvement (QAPI) program. Monitoring activities include: 100% review of all new admissions and physician orders for 90 days to verify that services are not initiated until orders are received. Monthly audits of at least 10% of clinical records thereafter to confirm that all documented services and treatments are supported by physician orders. The Director of Nursing will maintain a log tracking outstanding physician orders and follow up with providers until all orders are signed and returned. Audit findings will be reviewed during quarterly QAPI meetings and trended for ongoing compliance.

All six cited clinical records will be immediately reviewed by the Administrator/Director of Nursing (DON). The Director of Nursing will ensure that each affected patient has a developed and completed individualized Plans of Care (POCs) based on the most recent comprehensive assessment. The DON will Contact the responsible physicians to obtain review, revision, and signatures for each patient's POC. Ensured that all POCs reflected current patient status, measurable goals, interventions, and services being provided. Documented physician approval and placed signed POCs in the clinical record.

The agency will conduct a 100% audit of all active and discharged patient records for the previous 12 months to identify any additional patients affected by the same deficient practice. Any records identified without timely physician-reviewed POCs will be corrected.
To prevent recurrence: the agency implemented A Plan of Care tracking log was implemented to monitor POC due dates beginning from the Start of Care date and every 60 days thereafter. The agency re-educated all clinical and administrative staff on agency Policy.

To ensure ongoing compliance, the agency incorporated POC review and revision monitoring into its Quality Assurance and Performance Improvement (QAPI) program: 100% review of all new admissions and recertifications for 90 days to ensure POCs are developed and reviewed within required timeframes. Monthly audits of 10% of active clinical records thereafter to verify continued compliance with 60-day review requirements. The Director of Nursing will review the POC tracking log weekly to ensure no recertification or revision deadlines are missed. Audit results will be presented during quarterly QAPI meetings and trended to identify any patterns or areas needing additional training. Monitoring will remain in place until sustained compliance is demonstrated for two consecutive quarters.

All six cited clinical records will be immediately reviewed by the Administrator/Director of Nursing (DON) to ensure that there is Completed comprehensive assessments for all affected patients with current clinical status. Affected patient POC will be developed and/or revised to reflect: Updated patient assessments, measurable goals and outcomes, documentation of patient progress toward those goals. Al revised POCs will be submitted to the attending physicians for review, approval, and signature.


The agency conducted a 100% audit of all active and discharged records for the previous 12 months. To identify additional patients who may have been affected. Any record found to be missing this information was corrected by completing updated assessments and revising the plan of care accordingly, followed by physician review and signature.

To prevent recurrence, the agency implemented Plan of Care Revision Template to ensure all requirements are documented in the POC. All clinical staff received retraining on requirements for comprehensive assessments, documentation of patient progress, alignment between assessments, goals, and interventions.

To ensure compliance, the agency incorporated these elements into its Quality Assurance and Performance Improvement (QAPI) program: 100% review of all reassessments and recertification packets for 90 days to ensure revised POCs reflect updated patient information and progress toward goals. Monthly audits of at least 10% of clinical records. Audit findings are documented and reviewed during quarterly QAPI meetings, and any deficiencies will result in immediate corrective staff education and follow-up audits. Monitoring will continue until compliance is demonstrated for two consecutive quarters.

The agency acknowledges that its QAPI program did not demonstrate measurable outcomes, performance improvement activities, or performance improvement projects for calendar year 2025. The agency has taken immediate action to develop and implement a comprehensive, data-driven, agency-wide QAPI program.
The lack of an effective QAPI program placed all patients at risk for potential quality and safety issues. The Administrator and Director of Nursing conducted a clinical review of all active patients to verify compliance. Any identified clinical documentation or care coordination deficiencies were corrected immediately.

Because the deficient practice involved the absence of a functioning agency-wide QAPI program, all patients served during 2025 and current active patients were considered potentially affected. The agency performed: a retrospective review any trends or quality concerns identified during the review will be addressed through immediate corrective clinical interventions and documentation updates.

The agency has fully developed and implemented a structured Quality Assessment and Performance Improvement (QAPI) Program that includes: Governing Body Oversight.

The agency initiated its first formal Performance Improvement Plan. A standardized QAPI data collection tool was implemented. Quality data will be collected monthly and trended over time to identify performance patterns.
To ensure the QAPI program remains active and effective: Monthly QAPI meetings will be conducted with participation from administration, nursing, and contracted services. Meeting minutes, data reports, and action plans will be maintained as evidence. The agency will maintain documentation demonstrating the operation and effectiveness of the QAPI program and will present this documentation during any future surveys.

The agency acknowledges that it did not maintain documentation demonstrating an active, data-driven QAPI program capable of measuring, analyzing, and tracking quality indicators or demonstrating measurable improvement in patient outcomes, safety, and quality of care.
The Administrator/Director of Nursing conducted a review of all active patient records to verify compliance.

Because the deficiency involved the lack of a functioning QAPI program, all patients served within the last 12 months were considered potentially affected. The agency therefore: Conducted a retrospective review. Any trends or quality concerns identified during the review will be addressed through immediate corrective clinical interventions and documentation updates.
The agency developed and implemented a fully structured, documented, and data-driven Quality Assessment and Performance Improvement (QAPI) Program to meet regulatory requirements.

The agency implemented a tracking tools to ensure ongoing collection and trending of quality data. Data is now compiled monthly and analyzed to identify opportunities for improvement. All administrative and clinical staff received training on QAPI.

To ensure that the QAPI program remains active and effective: Monthly QAPI committee meetings will be conducted to review quality indicator data and identify trends. Meeting minutes, data reports, and action plans are maintained as documentary evidence. The Administrator ensures that quality indicators are measured, analyzed, and trended monthly, and that any negative trends result in corrective action plans or performance improvement projects (PIPs).

Although no immediate patient harm was identified during the survey, the absence of performance improvement activities placed patients at risk for unmonitored quality and safety concerns.

The agency acknowledges that it did not maintain documentation demonstrating that performance improvement activities were conducted or focused on high-risk, high-volume, or problem-prone areas as required. The agency has developed and implemented a structured process to identify, prioritize, and address performance improvement activities in accordance with federal requirements.
The Administrator/Director of Nursing conducted a review of all active patient records to identify any current clinical or safety concerns. Any issues identified during the review were corrected.

All patients served within the past 12 months were considered potentially affected. The agency conducted a retrospective review for compliance. To prevent recurrence the agency established criteria to identify performance improvement priorities.

To ensure ongoing compliance and sustained improvement: The agency conducts monthly QAPI meetings to review performance data and evaluate progress of active PIPs. Data related to identified high-risk areas is collected and analyzed monthly.

The Director of Nursing maintains documentation of all PIP activities, including meeting minutes, data analysis, corrective actions, and progress toward improvement goals.
Any performance issue that poses an immediate threat to patient health or safety will be corrected immediately, and the event will be reviewed during the next QAPI meeting to determine whether additional system changes are required.

The agency acknowledges that it did not demonstrate that performance improvement activities were tracked and monitored to ensure sustained improvements. The agency has implemented a corrective action plan to ensure that improvements are identified, implemented, and monitored for sustainability. The Director of nursing will review of all active patient records to identify any care gaps, missed interventions, or unmet needs.

All patients active in the past 12 months were considered potentially affected. The agency performed a retrospective review all gaps were addressed immediately with updated care plans, staff notifications, and physician communication.

All staff educated on QAPI requirements, importance of sustaining improvements, and their role in monitoring and reporting outcomes.

To ensure ongoing compliance and sustained improvement: The agency conducts monthly QAPI meetings to review performance data and evaluate progress of active PIPs. Monitoring is ongoing and will continue indefinitely as part of the agency's QAPI program.

The agency acknowledges that it did not conduct performance improvement projects (PIPs) as part of its QAPI program, and documentation of projects was not available at the time of survey. The agency has implemented a corrective action plan to ensure that PIPs are conducted, documented, and monitored for measurable outcomes.
The absence of documented PIPs placed patients at risk for missed opportunities to improve quality, safety, and outcomes. The agency performed conducted a retrospective review of all patient care records from the past 12 months. Any deficiencies will be corrected immediately through updated care plans, staff notifications, and physician coordination.


To ensure PIPs are conducted as required: the agency develop an annual schedule of at least three performance improvement projects. Each PIP will include a defined goal, baseline data, interventions, measurable outcomes, and a timeline for implementation. Staff will be trained on PIP methodology, data collection, and reporting requirements.

The agency will implement ongoing monitoring to ensure PIP effectiveness and sustainability.

Any PIP that does not achieve measurable outcomes will trigger immediate corrective interventions and process adjustments. Quarterly reports to the governing body will include PIP status, outcomes, and recommendations for further improvement.
Monitoring is ongoing and will continue indefinitely as part of the agency's QAPI program.

The agency acknowledges that it failed to maintain documentation of competency evaluations for clinical staff at the time of hire and annually thereafter, as required by agency policy and regulation. The agency has developed and implemented a corrective action plan to ensure staff competency is verified, documented, and monitored consistently.
The lack of documented competency evaluations placed patients at risk of receiving care from staff whose skills were not verified. The agency will conduct a retrospective competency assessment for all clinical staff currently employed and those who provided care in the past 12 months. This will ensure that staff providing care to patients have the necessary skills to safely provide services. The DON will immediately address any deficiencies in clinical knowledge or skills through targeted education, skills demonstration, or reassignment if necessary.

To ensure no patients are missed the agency will generate a list of all patients currently receiving services and those discharged within the last 12 months and cross-reference staff assigned to each patient with staff who lacked documented competency evaluations.

To prevent recurrence, all clinical staff will undergo competency evaluation at the time of hire, annually thereafter, and as needed based on performance. Staff will complete required skills review annually, including any changes in procedures, equipment use, or agency policy.
To ensure ongoing compliance: the DON will review competency documentation for all staff monthly and audit 10% of personnel files for verification of competency evaluations every quarter. Any gaps or deficiencies discovered during audits will trigger immediate corrective action, including additional training or reassignment. Monitoring and reporting will continue indefinitely to ensure competency compliance is sustained.

The agency acknowledges that the governing body failed to conduct and document a meeting that reviewed and approved the annual program evaluation and agency policies in accordance with agency policy. Lack of proper governing body oversight may indirectly affect patient care, quality assurance, and operational decision-making. There will be an immediate review of the 2025 Annual Program Evaluation and all current agency policies by the Governing Body to ensure compliance.

All patients active during the period of missing governing body oversight will be reviewed to confirm that quality and safety indicators were monitored appropriately through other internal checks. Any patients whose care may have been impacted by policies not reviewed or approved will be identified, and corrective actions will be implemented, such as review of care plans, documentation, and compliance with established agency standards.

To prevent recurrence The agency will at least annually wit al least 2 members. Meeting minutes will documented as evidence. The agency created an Annual meeting Calendar and send to each governing body members.
Director of Nursing/Administrator will audit the Governing Body minutes annually to ensure compliance.

The agency acknowledges that the Governing Body failed to appoint a qualified professional as Agency Administrator in writing and ensure documentation for the alternate administrator. Lack of a properly appointed administrator may indirectly affect patient care oversight, operational decision-making, and regulatory compliance. The Governing Body has formally appointed the current Administrator in writing, including a detailed job description, scope of authority, and responsibilities.

To prevent recurrence the Governing Body will appoint the Administrator and Alternate Administrator in writing annually or as changes occur. Job descriptions, competencies, and performance expectations will be documented in personnel files.
The Governing Body will conduct quarterly audits of personnel files to ensure: Written appointment of Administrator and Alternate Administrator exists, Job descriptions are current and signed, Competency assessments and performance evaluations are documented. Findings will be reported during QAPI meetings and any gaps will trigger immediate corrective action.

The agency acknowledges the finding that patient care orders and plans of care were not consistently developed and implemented by a Registered Nurse and authorized by a physician prior to the delivery of services. The agency has taken immediate and long-term corrective actions to ensure full compliance with Federal, State, and Local laws. All six (6) patients identified in the review had their records audited by the agency's Administrator and Director of Nursing. Physician Orders and Plans of Care: Missing physician orders and Home Health Certification/Plan of Care (POC) were obtained, documented, and incorporated into each patient's record. RN evaluations were conducted for all affected patients to ensure accurate assessment, implementation, and documentation of nursing care. Clinical staff involved in the care of these patients were retrained on policy requirements for obtaining physician orders and RN-authored POCs before service delivery.

The DON conducted an audit of all active patients to compliance with the requirements.
To prevent recurrence all new admissions now require RN verification of Signed physician orders and that services cannot begin without verification by the Administrator or RN. All clinical staff received retraining on compliance per the agency policy and regulations.

The administrator or the DON will conduct a Weekly Audit of New Admissions. The Administrator or Director of Nursing will review all new admissions for proper RN-authorization POC and physician orders. Any deficiencies will be corrected within 24 hours. A monthly Compliance Report will be presented at monthly QAPI meetings and reviewed by the Governing Body. Findings from audits and compliance reports will inform performance improvement projects to prevent recurrence.

The agency acknowledges that the Governing Body did not conduct and document a two-person meeting that included review and approval of the annual program evaluation, budget, and agency policies as required by regulation and agency policy. Corrective actions have been implemented to ensure the Governing Body fully assumes legal authority and responsibility for the operation of the agency and maintains proper documentation of its activities. The Governing Body conducted an immediate formal meeting with two members present to review: The annual program evaluation, the agency's written policies and procedures, the agency's operational and fiscal status.

Meeting minutes were completed, signed, and maintained in the agency records. Any policy changes affecting clinical operations were communicated to staff and implemented immediately to ensure safe and compliant patient care.
To prevent recurrence the Governing Body will meet at least annually, with no fewer than two members present. A standing agenda template has been developed to ensure required topics are addressed at each meeting. All meeting documentation will be maintained in the Governing Body binder for survey readiness.
Governing Body members received education regarding their regulatory responsibilities under Pennsylvania home health regulations and agency bylaws.
To ensure sustained compliance the Administrator will maintain a Governing Body Compliance Calendar that tracks: Quarterly meeting dates, annual policy review deadlines, Annual program evaluation approval dates. During quarterly QAPI meetings, the agency will verify that Governing Body meetings occurred as scheduled
The Governing Body will review compliance with its own bylaws annually as part of the agency's performance improvement activities.

The agency acknowledges that personnel files were incomplete and did not contain required documentation including CPR certification, TB screening, job descriptions, background checks, credentials, and orientation records. The agency has implemented immediate and systemic corrective actions to ensure all personnel records are complete, current, and maintained in accordance with Federal and Pennsylvania regulations.
The agency conducted an immediate review of all active clinical staff files. Staff who were missing required documentation were: removed from direct patient care duties until required clearances, certifications, and health screenings were completed. staff were required to provide current CPR certification, TB screening, and proof of credentials prior to returning to patient assignments. Criminal background checks, ChildLine clearances, and federal fingerprinting were obtained for all staff who did not have these documents on file. Updated job descriptions were issued, reviewed with staff, and signed.

To prevent recurrence the agency has implemented : A standardized Personnel File Audit Checklist was developed to ensure all required documents are present before hire and maintained annually. Pre-Hire Clearance Requirement that Staff cannot begin employment or provide patient care until all required background checks, credentials, and health screenings are verified and documented. The agency created a tracking log to monitor expiration dates of CPR and licenses, annual TB screening due dates and performance evaluation schedules
Administrative staff responsible for hiring and file maintenance were re-educated.
To ensure sustained compliance: The Administrator will conduct monthly audits of 100% of personnel files for three months, then quarterly thereafter. Findings will be reported to the Governing Body and included in the QAPI program as a monitored compliance indicator. Any missing documentation identified during audits will be corrected immediately, and staff will be removed from patient care if required credentials lapse.

The agency acknowledges that treatment plans were not developed, updated, or communicated to the attending physician every 60 days as required. The agency also failed to maintain documentation of interdisciplinary coordination and case conference communication. Immediate corrective actions and system-wide changes have been implemented to ensure coordinated patient care and physician communication in accordance with state regulations.
All patients identified in the survey findings were reviewed immediately. The Director of Nursing contacted each patient's attending physician to: Obtain or update physician orders, establish or revise a comprehensive plan of treatment addressing diagnoses, services, visit frequency, medications, safety measures, and discharge planning. A written 60-day summary report was completed and transmitted to each patient's physician. Clinical records were updated to include: Signed plans of treatment, Interdisciplinary communication notes, Documentation of physician correspondence.

The agency conducted a 100% audit of all active and recently discharged patient clinical records for compliance. Any additional patients identified without current physician orders or care plan updates had an immediate care plan development or revision and Physician notification and documentation added to the clinical record.
The agency implemented a 60-Day Recertification and Summary Tracking Log to monitor plan of treatment due dates, 60-day summary report deadlines and Physician signature status.
All clinical and administrative staff received training on requirements
To ensure ongoing compliance The Director of Nursing will perform monthly audits of 100% of active patient records for three months, followed by quarterly audits thereafter. Results will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings and reported to the Governing Body. Any missed deadlines or documentation gaps identified during monitoring will result in immediate corrective action and staff re-education.

The agency acknowledges that it did not conduct and document quarterly clinical record reviews in accordance with its own policy. Documentation did not include required elements such as services rendered, adherence to agency policies, adequacy of the plan of care, and need for continued services. Corrective actions have been implemented to ensure clinical record reviews are completed quarterly, properly documented, and used to evaluate the effectiveness and appropriateness of patient care.
The Director of Nursing conducted an immediate retrospective review of all active patient clinical records to evaluate compliance with the requirements. Any discrepancies identified during the review were corrected. To prevent recurrence the Quality Assurance Clinical Outcomes Committee has been formally re-established and scheduled to meet quarterly with participation from appropriate health professionals representing the scope of services provided by the agency. The agency developed and implemented a Clinical Record Review Form that includes required elements. The Administrator and clinical staff received re-education on requirements.

To ensure ongoing compliance the Administrator will maintain a Quality Assurance calendar identifying due dates for quarterly clinical record reviews. Meeting minutes and completed Clinical Record Review Forms will be maintained and reviewed during Governing Body and QAPI meetings. The Director of Nursing will verify completion of each quarterly review and ensure corrective actions identified during reviews are implemented and tracked to completion. Compliance with quarterly clinical record review requirements will be reported as a standing agenda item during QAPI meetings.

The agency acknowledges that a Home Health Certification and Plan of Care was not created or maintained for six (6) of six (6) clinical records reviewed. The agency also acknowledges that services were initiated without documented physician orders and without a comprehensive plan of treatment containing required clinical elements. Immediate corrective action and systemic changes have been implemented to ensure all patients receive services only under a physician-approved plan of treatment that meets regulatory requirements.

All patients identified in the survey findings were reviewed immediately. Services were reviewed to ensure they were medically necessary and consistent with physician orders. Where needed, services were suspended until appropriate orders were received.

To ensure no other patients were receiving services without a compliant plan of treatment the agency conducted a 100% audit of all active and recently discharged patient clinical records to verify.
To prevent recurrence the agency implemented a plan of care checklist to ensure all required regulatory elements are included and cannot be finalized unless all fields are completed. A tracking log was implemented to ensure plan of care are in compliance with the requirements.
The Administrator/Clinical Manager must review each plan of care for completeness prior to submission to the physician and again upon return for signature. All administrative and clinical staff received training on regulatory requirements for plans of treatment.
To ensure continued compliance The Director of Nursing will conduct weekly audits of all new admissions for three months to verify that plans of care are created within required timeframes and signed by physicians. Thereafter, audits will be conducted monthly and reported to the Quality Assurance and Performance Improvement (QAPI) program and Governing Body. Any identified deficiencies will be corrected immediately, and staff will receive re-education as necessary.

The agency acknowledges that services, treatments, and medications were provided without documented physician orders for six (6) of six (6) clinical records reviewed. The agency recognizes that this practice is not in compliance with state regulations or agency policy and has implemented immediate corrective actions and systemic safeguards to ensure all services are provided only under physician authorization.

All patients identified in the survey findings were reviewed immediately to ensure continuity of care and medical oversight. Any discrepancies between current care and physician direction were clarified with the physician and corrected immediately.
To ensure no other patients were receiving services without physician authorization the agency conducted a 100% audit of all active and recently discharged patient clinical records. Any patient record found lacking physician orders had orders obtained immediately and documented in the clinical record.
To prevent recurrence the agency has implemented, a Physician Order Tracking Log.
The Administrator/Director of Nursing must review each new admission file within 48 hours to verify that physician orders are present and complete. All clinical and administrative staff received training on requirements.

To ensure ongoing compliance The Director of Nursing will conduct weekly audits of all new admissions for three months to confirm that services are not initiated without physician authorization.

Thereafter, audits will be conducted monthly and incorporated into the agency's Quality Assurance and Performance Improvement (QAPI) program. Any deficiencies identified during monitoring will be corrected immediately and addressed through staff counseling and re-education.

The agency acknowledges that required Registered Nurse (RN) supervision of Licensed Practical Nurses (LPNs) and Home Health Aides (HHAs) was not performed or documented in accordance with agency policy and state regulations. Additionally, personnel files did not contain competency evaluations for multiple clinical staff. Corrective actions have been implemented to ensure all paraprofessional and licensed staff are appropriately supervised and competency-validated.
All patients identified in the survey findings were reviewed immediately to ensure safe and appropriate care. The Director of Nursing conducted immediate supervisory visits for all active patients receiving services from HHAs and LPNs. Any necessary corrections to care delivery were implemented and documented in the clinical record.

To ensure no other patients were affected by lack of supervision the agency conducted a 100% review of all active patient assignments to identify any non-compliance. Any cases found with deficiency RN supervisory visits were scheduled and completed for any patient lacking required oversight.
The agency implemented a Supervision Tracking Log, a Competency Evaluation checklist
To ensure sustained compliance the Director of Nursing will conduct monthly audits of all active cases for three months to ensure compliance with the requirements. Thereafter, supervision compliance will be reviewed quarterly through the agency's Quality Assurance and Performance Improvement (QAPI) program.

The agency acknowledges that complete clinical records were not maintained for six of six patient records reviewed. Specifically, the records lacked Plans of Care (POC), physician orders, and Registered Nurse documentation as required by agency policy and Pennsylvania regulations. Immediate corrective actions have been taken to ensure all patient records are complete, accurate, and maintained in accordance with regulatory standards.
All patient records identified in the survey findings were reviewed immediately by the Director of Nursing. To determine if additional patients were affected by incomplete clinical records the agency conducted a 100% audit of all active and discharged patient records within the past 12 months any record found to be incomplete was corrected.


To prevent recurrence the agency has implemented a Clinical Record Checklist at Start of Care for every new admission to ensure the clinical record is in compliance with the requirements. No patient will be scheduled for ongoing services until the checklist is completed and verified by the clinical manager. And Plan of Care Tracking Log created to track all POC. All clinical and administrative staff received re-education on requirements.
To ensure continued compliance The Director of Nursing or designee will perform monthly clinical record audits for the next three months to ensure compliance with the requirements. Audit results will be presented during the agency's Quality Assurance and Performance Improvement (QAPI) meetings. After three months of full compliance, audits will transition to a quarterly review process. Any incomplete record identified during monitoring will be corrected immediately and staff involved will receive re-education.

The agency acknowledges the cited deficiency and has taken comprehensive corrective action to ensure that: All patients receive care in accordance with physician orders and an established Plan of Care. Clinical records are maintained in full compliance with the regulations. Systems are now in place to prevent recurrence and ensure ongoing monitoring. The Administrator and Director of Nursing are responsible for ensuring sustained compliance.
All six (6) patient clinical records identified during the survey were immediately reviewed by the Administrator and Director of Nursing upon notification of the deficiency.

To ensure no additional patients were affected by the deficient practice, the agency conducted a 100% audit of all active and discharged patient clinical records for the period:
Any record identified as missing required documentation was corrected using the same process described above.

To prevent recurrence, the following system changes have been implemented: A Plan of Care checklist has been added to the Start of Care and Recertification workflow. Clinical staff are now prohibited from scheduling visits beyond the initial assessment unless a physician-signed Plan of Care is on file or documented as pending.

The Director of Nursing or designee must review and approve each Plan of Care for completeness prior to submission to the physician, as required by agency policy. A new has been implemented to monitor compliance. All clinical and administrative staff received retraining on regulation.

To ensure ongoing compliance, the agency has implemented the following Quality Assurance measures: The Director of Nursing will conduct monthly audits of 10% of active clinical records. Audit results will be presented at quarterly Quality Assurance and Performance Improvement (QAPI) meetings to identify trends and implement corrective action if compliance falls below 100% . 100% of patients must have a physician-signed Plan of Care within required timeframes. Any identified deficiency will trigger immediate corrective action and staff counseling.

The agency acknowledges the finding that the Department of Health was not notified in writing regarding the change in administration. The Department of Health was not notified in writing regarding the change in administration.

To prevent recurrence The Governing Body will review any management changes at the next scheduled meeting and ensure timely reporting to the Department. A notification checklist has been created to track reporting deadlines for all future administrative changes.

The Governing Body and Administrator will review all changes in administration quarterly to ensure notifications to the Pennsylvania Department of Health are submitted within 30 days of any management changes. Documentation of notification, including copies of letters sent and confirmation of receipt, will be maintained in the agency's regulatory compliance binder. Findings and any corrective actions will be reviewed during QAPI meetings and documented.